The proposed project is responsive to research objectives #4 and #5 of this FOA: to evaluate recent changes in policies or environments that could influence the rising rate of prescription drug overdoses (#4), and to inform policy debate on prescription drug overdose prevention using secondary data analyses (#5). Objectives: The overarching goal of this proposal is to explore the utility and effectiveness of two statewide prescription monitoring programs (PMPs), in Connecticut (CT) and Rhode Island (RI), in reducing prescription opioid-involved accidental intoxication deaths among adults. Importance: Beyond their law enforcement application, PMPs may have broader utility in reducing overdose deaths as a form of structural public health intervention that can influence diversion and access to medications and as a generator of unique public health data. Results from this research will help understand how PMPs are currently being used and their potential for prescription opioid overdose surveillance and prevention. Specific Aims: (Aim 1) To determine if PMP data can detect an association between opioid diversion and aberrant opioid utilization and risk of prescription opioid accidental overdose death by conducting a matched case-control study among adults in CT and RI. We will first: (Aim 1a) refine the definition of aberrant opioid utilization (i.e., doctor shopping) using prescription "fill" data compiled by PMPs;and (Aim 1b) perform a forensic case investigation of medical examiner cases to identify cases and controls;(Aim 2): To assess whether state PMPs are, at present, being used in a way to detect overdose risk by: (Aim 2a) conducting an online survey of prescribers and dispensers on use of the PMP and (Aim 2b) examining associations between the geographic distribution of residence of decedents of prescription opioid overdose, use of the PMP, and the amount of prescribed opioid dispensed in the community;and (Aim 3) To conduct a rapid assessment and response (RAR) to verify that PMPs and other data sources generate data reflective of high prescription opioid overdose risk in two communities, one in RI and one in CT, and to determine ways that PMPs and other responses can be used to prevent fatal prescription opioid overdose there. Study Design: a) Case-control analysis, b) cross-sectional survey, and c) RAR ethnographic investigation. Setting/Participants: a) all deaths involving drugs among adults occurring in CT and RI during 2009 from the state medical examiner's office databases who also appear in the PMP database. Cases will be those accidental intoxication deaths involving a prescription opioid as the only opioid. Controls will be drug-involved deaths of any intent, matched to the case on age group, county of residence, and month of death. b) CT clinicians (n=1400) and pharmacists (n=210) registered to use the CT PMP, RI pharmacies (n=200) who upload prescription data, and RI licensed providers (n=7955) will be surveyed. c) two cities/towns, one in RI and one in CT, experiencing high rates of fatal prescription opioid-involved overdose. Intervention: None. Outcome measures: 1) fatal prescription opioid overdose events;2) diversion of prescription opioids;3) doctor/pharmacy shopping;4) use of PMP by providers (self-reported, administrative records);5) community-verified: prescription opioid overdose problem definition and potential prevention benefit of PMP. PUBLIC HEALTH RELEVANCE: Prescription monitoring programs (PMPs) may have broader utility to patients, prescribers, pharmacists, decision makers and to society both as a form of structural public health intervention that can influence diversion and access to medications and as a source of unique public health data. This study will help understand the potential public health application of PMP data to reducing unintentional fatal prescription opioid overdose through linkage of medical examiner, PMP, and other state agency data in Connecticut and Rhode Island and by conducting community-based field investigations in two New England communities found to be experiencing high rates of prescription overdose death.